Nokea
The patient is admitted with shortness of breath and chest discomfort. Which laboratory value could account for the patient's symptoms?
- A. Red blood cell count of 5.0 million/mm3
- B. Hemoglobin level of 8.0 g/100 mL
- C. Hematocrit level of 45%
- D. Pulse oximetry of 95%
Correct Answer: B
Rationale: Shortness of breath and chest discomfort suggest reduced oxygen delivery. Hemoglobin of 8.0 g/dL (B) indicates anemia (normal 12-16 g/dL), impairing oxygen transport. RBC 5.0 million/mm3 (A) and hematocrit 45% (C) are normal. Oximetry 95% (D) is adequate. Choice B is correct, linking anemia to symptoms per nursing pathophysiology.
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The nurse needs to obtain a radial pulse from a patient. What must the nurse do to obtain a correct measurement?
- A. Place the tips of the first two fingers over the groove along the thumb side of the patient's wrist.
- B. Place the tips of the first two fingers over the groove along the little finger side of the patient's wrist.
- C. Place the thumb over the groove along the little finger side of the patient's wrist.
- D. Place the thumb over the groove along the thumb side of the patient's wrist.
Correct Answer: A
Rationale: Radial pulse is palpated with the first two fingers along the thumb side groove (A), ensuring accuracy without thumb pressure interference. Little finger side (B, C) is incorrect anatomically. Thumb use (C, D) distorts readings. Choice A is correct, per nursing technique standards, for reliable radial pulse measurement.
A patient is experiencing pyrexia. Which piece of equipment will the nurse obtain to monitor this condition?
- A. Stethoscope
- B. Thermometer
- C. Blood pressure cuff
- D. Sphygmomanometer
Correct Answer: B
Rationale: Pyrexia (fever) requires temperature monitoring, making a thermometer (B) essential. A stethoscope (A) assesses heart/lung sounds, not temperature. A blood pressure cuff (C) or sphygmomanometer (D) measures pressure, not fever. Choice B is correct as thermometers directly track temperature changes, a fundamental tool in nursing to manage and document febrile states accurately.
A nurse is caring for a group of patients. Which patient will the nurse see first?
- A. A crying infant with P-165 and R-54
- B. A sleeping toddler with P-88 and R-23
- C. A calm adolescent with P-95 and R-26
- D. An exercising adult with P-108 and R-24
Correct Answer: A
Rationale: An infant with pulse 165 and respirations 54 (A) is borderline high (normal 120-160, 30-60), plus crying suggests distress, warranting priority. Toddler (B), adolescent (C), and adult (D) values are normal for context. Choice A is correct, per triage prioritizing potential instability.
The nurse needs to increase heat conservation in a newborn. Which action will the nurse take?
- A. Apply just a diaper.
- B. Double the clothing.
- C. Place a cap on their heads.
- D. Increase room temperature to 90 degrees.
Correct Answer: C
Rationale: Newborns lose heat rapidly, especially from the head, due to a large surface area and limited thermoregulation. Placing a cap (C) conserves heat by covering this key area, a standard neonatal practice. A diaper alone (A) offers minimal coverage, increasing heat loss. Doubling clothing (B) helps but is less effective than a cap for head protection. Raising the room to 90?°F (D) risks overheating. Choice C is correct, supported by pediatric guidelines (e.g., AAP) emphasizing head coverage to maintain newborn temperature stability.
When taking the pulse of an infant, the nurse notices that the rate is 145 beats/min and the rhythm is regular. How should the nurse interpret this finding?
- A. This is normal for an infant.
- B. This is too fast for an infant.
- C. This is too slow for an infant.
- D. This is not a rate for an infant but for a toddler
Correct Answer: A
Rationale: Infant pulse ranges from 120-160 beats/min; 145 (A) is normal with regular rhythm. Too fast (B) or slow (C) misaligns with norms. Toddler rates (D) are lower (80-130). Choice A is correct, per pediatric vital sign standards.